Introduction
Throughout the years it is likely that many changes have occurred in the way that psychotherapy is conducted. While much earlier in its history, it seems that theory and technique might have been the primary, and in some cases the only, focus in the treatment situation. However, the change that has arguably occurred is a shift towards recognizing and appreciating the importance of the relationship between the clinician and client, and the impact it has on the outcome of the therapy. This paper will focus on a combination of two aspects of the therapeutic alliance: Is the clinician-client relationship critical to the outcome of therapy? What are the critical elements of forming these collaborative client relationships? Is the clinician-client relationship critical to the outcome of therapy?
Critical is a strong word to use in describing just how important the relationship between client and clinician is to the eventual outcome of the therapy. It seems much more likely that a strong relationship is an integral aspect of a good outcome in therapy. Certainly, a negative relationship could prove to be a significant obstacle for the client to move forward in therapy. An article from 2015 in the Journal of Clinical Psychology suggests that a good therapeutic relationship may be a prerequisite for treatment to move forward; however, the authors do suggest that is “crucial to effective work” (Kazantis, Cronin, Norton, Lai, and Hofmann, 2015). An important distinction that might need to be made is the how to actually characterize what kind of client-clinician relationship is needed for a good therapeutic outcome. A good relationship should not necessarily be perceived to be a happy relationship or one that is always nice. A good working relationship would seem to reflect commitment on both parties to the therapeutic process, as well as the client’s understanding and acceptance that whatever is revealed in treatment is held in strict confidence. A strong working relationship means that the client is in a safe space in which problems can be addressed and, in time, resolved. A strong client-clinician relationship indicates that a partnership has developed, and that each partner has respect for the other. It is not, and cannot be, a one-way street. The work of the therapeutic alliance does not end with the establishment of a sold relationship between client and clinician. Part of maintaining the therapeutic alliance depends on how well the clinician is able to keep the client interested and motivated in the therapeutic process. Even a solid relationship can begin to become strained if the work does not seem to be progressing as either or both of the participants might have anticipated.
What are the critical elements of forming these collaborative client relationships?
Although as noted, the importance of the relationship was certainly valued earlier in the history of the profession. Indeed, as early as 1957, Carl Rogers emphasized a group of six conditions, which he believed were ‘necessary and sufficient’ for a client to be able to experience therapeutic change. These six conditions can all be characterized as fitting the parameters of the therapeutic alliance, and the difference that can be made when there is a strong relationship between the clinician and the client. It should also be noted, however, that Rogers emphasized the importance of the relationship not only for client-centered therapy. Feller and Cottone, 2003, cite these six conditions as: “counselor congruence or genuineness in the therapeutic relationship, unconditional positive regard for the client (warmth), the ability of the counselor to empathize with the client in this relationship, and communication of empathy and unconditional positive regard to the client” (p. 53). On this same topic, and with respect to Rogers, researchers emphasize the fact that although there are multiple factors that can come into play with respect to any treatment modality, it appears that when based on a single aspect, progress and outcome tend to be largely based on the relationship between the client and the therapist (Murphy and Cramer, 2014). The genuineness or authenticity of the counselor seems to be the one ‘ingredient’ that might reflect the greatest importance. Clearly, if a client begins to sense or in some way perceive that a counselor is not being straightforward or honest in some way, it could be difficult, if not impossible, for a client to move forward in a relationship of that nature. Trust is arguably the foundation of a strong and positive relationship, and this is perhaps even more compelling in a therapeutic relationship. However, additional factors might also need to be considered. For example, Manso and Rauktis (2011) make the point that adult clients and youth clients have different views about the therapeutic alliance. Whereas an adult client might look at things from a place of optimism and even stability, younger clients are much more likely to question and criticize an alliance they might have with an adult. Younger clients are much more focused on the qualities and characteristics of the individual person. They tend to seek out adults that reflect the ability to be both understanding and caring, open-minded, and emotionally stable. A good therapeutic alliance between a younger client and a clinician requires the ability for the clinician to maintain a balance in which his or her expectations do not come across as being too inflexible or authoritarian (Manso and Rauktis, 2011).
Moreover, another aspect of developing a therapeutic relationship with younger clients, especially children, relates to the reality that children often have multiple alliances that are likely to find their way into the relationship between young client and the clinician. Indeed, the work with younger clients can add many other variables into the mix that can arguably have an impact on the relationship between client and therapist (Lasky, Taylor, and Weist, 2012). In closing, an interesting point was raised during the research for this paper. In her paper, Bachelor (2013) focused on the respective views of clients and therapists in terms of how they each saw the therapeutic alliance in their respective client-therapist relationships. Although this might not necessarily be surprising, the author indicates that her findings suggest that the views held by therapists about therapeutic alliances do not necessarily align with the views of their clients. Bachelor concludes that this is an indication that therapists would be best served by frequently getting feedback from their clients regarding the relationship and how the client feels the work is progressing. It could prove to be enlightening information, which might ultimately influence the outcome of the therapy.